Perhaps you've seen something similar to this picture in the news recently... I sat and listened to a news clip this week about Dennis Quaid's twins being given 10,000 units instead of 10 units of a drug while in the hospital. Its Heparin; one of the most common drugs we give. In fact, I draw it up myself most days. It prevents deep vein thrombosis (aka blood clots), preventing stokes, pulmonary embolus, etc. While I was watching that clip I found myself feeling sympathy NOT for the Quaids but for the nurse who made the mistake. Although the hospital may not have fired her, the mental anguish she must be feeling from picking up the wrong vial when 10,000 other things were probably infringing on her mental decision-making capacities must be staggering. Her career could be ruined. Yes, ultimately, she should have scrutinized the label on the vial, but who knows what else was going on at the time? Were family asking multiple questions, was her other patient crashing, was a student nurse distracting her, had pharmacy or another nurse put the vials in a different place than usual, had she not gone to the bathroom or eaten in 7 hours? When under such time constraints, how can you be expected to not rely on some aspects of your daily routine?
The sad thing is nurses face decisions like this every day. What's even more disturbing is that we don't stand up to support each other and say, "It could have happened to any of us, its a part of the job." More often we watch quietly thinking "Mistakes are just a professional hazard," silently wondering when we could be next. Because
it could happen to any nurse, on any given day. In four years of nursing, I've made potentially dangerous medication errors twice. That's why many of us get out of the front lines of nursing to a place where the stakes are lower. No drugs to give, just making the policies that facilitate the pressure on those caregivers.
Several friends of mine have been present when nurses have made these horrific mistakes. Its usually under high pressure circumstances like when a patient is coding and seconds could mean life or death. There is little time then to scrutinize the vial and read the exact dosing information. By the time you do that, the patient is dead. So does the nurse get credit for being one of those with enough guts to try to save a life, or only get blamed because her actions didn't quite add up to her intentions? Sadly, many such cases have ended up in psychiatric treatment for these professionals.
For me personally, I can look back and see many times where God has been by my side on the floor; bringing to mind things I've forgotten, nudging me toward decisions, and guiding my thoughts so I can give better care. I can feel God's hand on me when I am at work more heavily than at any other time it seems. He's the reason I'm able to show up every day and face the pressure of nursing.
Obviously, blatant negligence and poor quality control issues need to be addressed. Some errors are made due to gross negligence by professionals and policies. I commend the Quaids (so far) on suing only the drug company in the hopes of creating effective change so the vials will be more easily differentiated. I can only hope that positive change will happen as a result of this episode but somehow I highly doubt our sue-happy, perfectionistic society will learn anything.
So here's to all those nurses who work in the front-line trenches everyday where the standards are high, the demands are tough, but the rewards are even greater. Because its here where the difference is really made...
Today (Dec 26) is Dorinda's birthday so she got sung to with birthday brownies.
